| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.91(a) | Per documentation in the Individual Record, Individual #4's two most recent Fire Safety trainings occurred on 05/23/2023 and 03/22/2022--more than 365 calendar days apart. This individual was not reinstructed in fire safety topics annually as required. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility. | The Lift Center will ensure that individual #4 and all other individuals served at The Lift Center receive Fire Safety training with 365 calendar year. |
04/01/2024
| Implemented |
| 2380.111(a) | Individual #1 was admitted to the provider's adult training facility effective 02/12/2024. The only individual physical examination on file was completed on 02/15/2024---after the individual's admission to the program. Individual #1 did not have a physical examination completed within 12 months prior to admission as required. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Lift Center has obtained a physical for individual #1 dated --------.
The Lift Center will ensure that all other individuals served at The Lift Center have physicals that are dated 365 days prior to the individual's initial enrollment/ start date. |
04/01/2024
| Implemented |
| 2380.111(c)(5) | Individual #2's physical examination, dated 07/17/2023, did not include Tuberculin skin testing with negative results noted or an initial chest X-ray with results noted. There was a Mantoux test found within Individual #2's Individual Record that was administered on 07/11/2022 and read negative on 07/13/2022; however, as this Tuberculin skin test occurred more than 365 calendar days prior to the individual's 10/02/2023 date of admission, it was insufficient to meet the requirement. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | The Lift Center obtained a copy of the individual #2 Tuberculin skin testing (results was negative.) The Lift Center has learned that the Tuberculin test is required to be administered within 365 calendar days of admission into the day program.
The Lift will ensure to be in receipt of a complete physical for individual #2 and all other individuals moving forward. |
04/01/2024
| Implemented |
| 2380.111(c)(6) | Individual #1's physical examination, dated 02/15/2024, did not note whether the individual was free from communicable diseases. | The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals. | The Lift Center obtained a completed updated physical form that indicates that individual #1 is free/ not free of communicable disease.
The Lift Center will ensure that all physicals are completed by the individual's PCP within 365 calendar days prior to their initial start date. |
04/01/2024
| Implemented |
| 2380.111(c)(7) | Individual #3's physical examination, dated 09/19/2023, did not include an assessment of the individual's health maintenance needs or the need for blood work at recommended intervals. There was a line item on the physical form asking whether this was applicable for the individual, which provided a "yes" checkbox, a "no" checkbox, and a line to record additional information. All of these areas were left blank by the medical professional completing the physical form. This information could not be located elsewhere in the physical. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The Lift Center obtained a physical for individual #3 from the CLA in PDF file with areas indicating the individual's Specific Health Maintenance Recommendations / Needs (Diet, Exercise, Medication Eval, Blood Work, etc.): checked (NO).
The Lift Center will ensure that all physicals are completed by the individual's PCP within 365 calendar days prior to their initial start date. |
04/01/2024
| Implemented |
| 2380.111(c)(8) | Individual #3's physical examination, dated 09/19/2023, did not include the physical limitations of the individual, if any. A line item on the physical form that read "Physical Limitations" was left blank by the medical professional completing the form. Another line item on the physical form read "Medical problems/limitations" with checkboxes corresponding to "yes" and "no" and a line to record additional information, all of which were left blank by the medical professional completing the form. This information was not denoted clearly in other areas of the physical examination. | The physical examination shall include: Physical limitations of the individual. | The Lift Center obtained a physical for individual #3 from the CLA in PDF file with areas indicating the individual's physical limitations that indicated he has no physical limitations.
The Lift Center will ensure that all physicals are completed by the individual's PCP within 365 calendar days prior to their initial start date. |
04/01/2024
| Implemented |
| 2380.111(c)(9) | Individual #1's physical examination, dated 02/15/2024, did not note the individual's allergies or contraindicated medications, if any, or lack thereof. | The physical examination shall include: Allergies or contraindicated medication. | The Lift Center was able to obtain individual #1 physical dated 10/5/2023 however the medical information was documented on the same form which did not address allergies or contraindicated medications. |
04/01/2024
| Implemented |
| 2380.111(c)(10) | Individual #1's physical examination, dated 02/15/2024, did not include medical information pertinent to diagnosis and treatment in case of an emergency.
Individual #3's physical examination, dated 09/19/2023, did not include medical information pertinent to diagnosis and treatment in case of an emergency. The line item for this information on the physical form was left blank by the medical professional completing the form, and the information was not found elsewhere throughout the physical examination. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Lift Center was able to obtain individual #1 physical dated 10/5/2023 however the medical information pertinent to diagnosis and treatment was documented on the same form which did not address obtain information. |
04/01/2024
| Implemented |
| 2380.113(c)(3) | Staff #1's most recent physical examination, dated 09/28/2022, did not note whether the staff was free of communicable diseases. The physical form has a line item asking, "Did this individual have any communicable disease?" with spaces to mark "yes" or "no." Neither the "yes" nor the "no" option was checked off by the medical professional completing the form, and this information was not found elsewhere on the physical form. | The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in § 27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals. | The Lift Center faxed a request to Lehigh Valley Health Network (610) 402-9293 requesting to have the staff #1 physical form completed in full to indicate if the staff was free of serious communicable disease. |
04/01/2024
| Implemented |
| 2380.173(1)(iv) | Individual #4's Individual Record did not contain information related to the individual's Religious Affiliation or lack thereof. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | The Lift Center will ensure that individual #4 record reflect her Religious Affiliation moving forward. The Lift Center reviewed the ISP and could not locate the religious affiliation. |
04/01/2024
| Implemented |
| 2380.181(d) | Individual #2's Initial Individual Assessment, dated 12/22/2023, was not signed and dated by the program specialist.
Individual #3's Individual Assessment, dated 02/01/2024, was not signed and dated by the program specialist.
Individual #4's Initial Individual Assessment, dated 02/02/2024, was not signed and dated by the program specialist. | The program specialist shall sign and date the assessment. | The Lift Center Program Specialist have signed individual #2 initial individual assessment.
The Lift Center Program Specialist have revised all initial individual assessments to include signature and dated lines. |
04/01/2024
| Implemented |
| 2380.181(e)(10) | Individual #3's Individual Assessment, dated 02/01/2024, does not contain a complete Lifetime Medical History (LTM). There is section in the Individual Assessment with the heading "Lifetime Medical History"; the most recent dates in this section are from the year 2020. Individual #3's Individual Record contains documentation of a medical appointment occurring on 07/06/2022 where the concern addressed was "concussion without loss of consciousness." As this serious medical event was not recorded in the LTM, the LTM was not updated and complete. | The assessment must include the following information: A lifetime medical history. | The Lift Center Program Specialist obtained individual #2 lifetime medical information and added it to the Annual Assessment dated January 31, 2024 Lifetime Medical History.181(3)(10). |
04/01/2024
| Implemented |
| 2380.126(a)(11) | Individual #1 is administered medications by adult training facility staff during program hours. There was no diagnosis or purpose noted for the following medications on the facility's March 2024 Medication Administration Record (MAR): Valproic Acid 250mg/5ml and Levocarnitine (Carintor) 100mg/ml Solution. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Individual #1's mother the primary care physician and authorized the release of medical information for The Lift Center.
The Lift Center is waiting to receive updated prescription indicating name medication and purpose of medication(s) administered by the Lift Center during operating hours. |
04/01/2024
| Implemented |